1 Introduction to Substance Abuse Awareness for Seniors A Guide for Developing a Substance Abuse Awareness Program for Older Adults Unifying science, education and services to transform lives. APRA Addiction Prevention and Recovery Administration
3 i Published in 2006 by the Central East Addiction Technology Transfer Center The Danya Institute 8737 Colesville Road, Suite 300 Silver Spring, MD This publication was prepared by the Central East Addiction Technology Transfer Center (Central East) under a cooperative agreement with the Substance Abuse and Mental Health Services Administration s (SAMHSA) Center for Substance Abuse Treatment (CSAT). All material appearing in this publication except that taken directly from copyrighted sources is in the public domain and may be reproduced or copied without permission from SAMHSA/ CSAT or the authors. Citation of the source is appreciated. Do not reproduce or distribute this publication for a fee without specific written authorization from the Central East Addiction Technology Transfer Center. For more information on obtaining copies of this publication, call the Central East ATTC at (240) Charles G. Curie, M.A., A.C.S.W., served as the SAMHSA Administrator. H. Westley Clark, M.D., J.D., M.P.H., served as the CSAT Director. Catherine Nugent, M.S., L.G.P.C., served as the Project Officer. Thomas Durham, Ph.D., served as the Central East ATTC Project Director, Robert L. Johnson served as Senior Deputy Director for the Addiction Prevention and Recovery Administration (APRA). The opinions expressed herein are the views of APRA and the Central East ATTC and do not reflect the official position of the U.S. Department of Health and Human Services (DHHS), SAMHSA or CSAT. No official support or endorsements by DHHS, SAMHSA, or CSAT for the opinions described in this document is intended or should be inferred. Photographs: istockphoto.com, Dreamstime.com and Photospin.com
5 iii Table of Contents Introduction...v Acknowledgements... vii Dear Colleague... ix Preface... xi PART 1: Understanding Substance Abuse Among Seniors...1 Overview of Substance Abuse Among Seniors...1 A Hidden Epidemic...1 A Growing Problem...2 A Changing Population...3 Reasons for Substance Abuse...3 Special Health Considerations...5 Treating Substance Abuse in Seniors...6 Challenges and Barriers to Getting Seniors Into Treatment...6 Treatment Options and Special Considerations for Seniors...8 Treatment Approaches...15 Case Management, Discharge Planning and Continuing Care...16 Substance Abuse Treatment Guidelines for Seniors...17 Resources for Additional Information...19 PART 2: Developing a Substance Abuse Awareness Program for Seniors...21 Outreach and Education Strategies...21 Determining the Needs of Your Senior Population...21 Selecting Outreach and Education Venues...24 Designing Education Programs for Seniors Ten Steps for Success...24 Special Considerations for Development of a Senior Substance Abuse Awareness Program...36 Culture and Language...36 Tips for Conducting Effective Senior Outreach/Education Programs...38 Program Sustainability...39 Resources for Additional Information...40
6 iv PART 3: Providing Linkages to Substance Abuse Treatment and Related Services...41 Conducting Substance Abuse Screenings...41 Talking with Seniors about Substance Abuse...41 Screening Tools...42 Medication Reviews...42 Referrals and Case Management...44 Legal Issues and Confidentiality...44 Resources for Additional Information...45 PART 4: Involving Auxiliary Service Providers in Raising Awareness of Substance Abuse Among Seniors...47 Education and Awareness-Raising Strategies...47 Training Professionals...48 Curriculum Development...48 Training Tips...49 Evaluation...49 APPENDICES Appendix A: Sample Needs Assessment Instruments...51 Appendix B: A Sample Program and Client Materials from the Substance Abuse Awareness for Seniors (SAAS) Program...61 Appendix C: Sample Substance Abuse and Other Screening Instruments...91 Appendix D: Using Icebreakers in Raising Substance Abuse Awareness Among Seniors Appendix E: Resource List Appendix F: References...135
7 v Introduction Substance Abuse Awareness for Seniors: A Guide for Developing a Substance Abuse Awareness Program for Older Adults There is a new sense of urgency surrounding the topic of aging and addiction. More than eight million older adults currently suffer from addiction to alcohol, medications or other chemical substances, and the numbers will swell as Baby Boomers age. The need for awareness among care providers has never been greater, because there is still little understanding or acknowledgement of the disease of addiction in older adult populations. This manual will not only raise awareness of the scope and nature of this alarming epidemic, but it offers a basic guide to prevention, assessment, intervention, treatment and aftercare. It also explores underlying factors that keep the disease hidden and treatment and recovery elusive for millions. Written in clear, concise language and organized with practical guidelines throughout, the manual is an essential reference piece for practical implementation and resources. Thanks to the Central East Addiction Technology Transfer Center, the Danya Institute and the District of Columbia Department of Health, Addiction Prevention and Recovery Administration for compiling this vital guide and making it widely accessible. The collaboration of these agencies brings into focus why and how we can stem the economic and human toll that the disease of addiction takes on society, families and individuals. Carol Colleran, Executive Vice President, public policy and national affairs, Hanley Center, West Palm Beach, Florida.
9 Acknowledgements vii THIS DOCUMENT WAS DEVELOPED IN PARTNERSHIP WITH: The Central East Addiction Technology Transfer Center The Addiction Prevention and Recovery Administration, Department of Health, District of Columbia PRIMARY CONTRIBUTORS: Donna Ruscavage, Primary Author Cassandra Hardison Cynthia Moreno Tuohy
11 Dear Colleague, ix The primary aim of the publication is to address a growing dilemma in our society: the increasing number of senior adults who are addicted to alcohol and other drugs. There is also a sense of urgency due to the anticipation of the entrance of the Baby Boom generation into the ranks of seniors. In light of this emerging dilemma, we must increase our efforts at substance abuse prevention while honing our skills at intervention and treatment regarding substance use disorders among this growing number of older adults. The use of the material in this manual is a significant step in that direction. I would like to acknowledge a number of people who deserve recognition for the development and publication of this document. This manual was the vision of representatives of the District of Columbia s Addiction, Prevention and Recovery Administration (APRA) and the Central East Addiction Technology Transfer Center (Central East). Originally spearheading this effort were Cynthia Moreno Tuohy, former Project Director of the Central East; Kevin Shipman, Manager of the Office of Special Population Services at APRA; and Cassandra Hardison, Public Health Analyst/Substance Abuse Awareness for Seniors Program Coordinator at APRA. The primary author of this document is Donna Ruscavage, an experienced editor and writer whose previous work includes writing and editing on health issues for the popular press, health-related Internet Web sites and professional publications. Contributions were also made by Ms. Moreno Tuohy, Ms. Hardison, and Frances Lorenzi, the Central East Director of Training. Finally, I would like to recognize two individuals whose insight and action led to the initiation of the Substance Abuse Awareness for Seniors Program for the District of Columbia. Sue Whitman, former Chairman of the Washington Mayor s Long Term Care Committee, and the late Dr. Larry Segal former Deputy Director of Substance Abuse Services for the District of Columbia, were instrumental in the development of the Seniors Program, without which the vision for the development of this manual would not have existed. I expect you will find this manual to be a practical guide and significant reference to use in the design and implementation of prevention, intervention and treatment services for senior adults with substance use disorders. Sincerely, Thomas G. Durham, Ph.D. Executive Director, The Danya Institute and Project Director of the Central East Addiction Technology Transfer Center
13 Preface xi How To Use This Guide Substance abuse including alcohol, illegal drugs and prescription drugs among persons 60 years or older has become a hidden epidemic across the United States, affecting persons of all races, ethnicities and income levels. While substance abuse is increasing at an alarming rate among seniors, there is a lack of specialized information for the provider community on the importance of and strategies for raising awareness about senior substance abuse. This guide seeks to address this information gap by presenting how to information on designing and implementing effective substance abuse awareness programs for older adults. Its intention is to build capacity among providers in order to address this critical growing issue. Target Audience: The guide targets a wide audience of providers and professionals including substance abuse professionals, substance abuse treatment providers, organizations serving seniors and professionals working with seniors on issues that relate to or involve substance abuse. The information provided will assist in their efforts to familiarize other providers, as well as seniors themselves, with the types of substance abuse issues that older adults face with increasing frequency. In addition, it will provide specific tools and strategies they can use to address these issues. Collaborators: The guide is a special collaboration between the Central East Addiction Technology Transfer Center (Central East), the Danya Institute and the District of Columbia Department of Health, Addiction Prevention and Recovery Administration (APRA). APRA s Substance Abuse Awareness for Seniors Program (SAAS) provided significant contributions to the content of this manual. Guide Organization: The guide is organized into four main parts and appendices of additional information and resources. Part 1: Understanding Substance Abuse Among Seniors. Discusses statistics, trends and issues around substance abuse and seniors. Identifies challenges and barriers to treatment. Describes treatment modalities and special considerations for seniors. Provides specifics on case management, discharge planning and continuing care. Lists general substance abuse treatment guidelines for seniors. Part 2: Developing a Substance Abuse Awareness Program for Seniors. Outlines outreach and education strategies and walks readers through a ten-step process for designing awareness programs. Discusses special considerations in program development, including culture and language. Provides tips for conducting effective programs and addresses program sustainability.
14 Part 3: Providing Linkages to Substance Abuse Treatment and Related Services. Gives tips for talking with seniors about substance abuse, identifies commonly used screening tools and talks about medication reviews. Provides information regarding referrals and case management and discusses legal issues and confidentiality. Part 4: Involving Auxiliary Service Providers in Raising Awareness of Substance Abuse Among Seniors. Provides education and awareness-raising strategies regarding engaging and training professionals. Provides information on evaluating training activities. Appendices. Contains sample documents from the District of Columbia APRA Senior Substance Abuse Awareness Program, substance abuse and related screening instruments, a discussion on using ice breakers in outreach activities, a resource list and a list of references used in the preparation of this guide.
15 Understanding Substance Abuse Among Seniors Part 1 1 Overview of Substance Abuse Among Seniors A Hidden Epidemic Did you know that older adults, 60 years and older, make up one of the fastest growing groups of U.S. citizens who are affected by substance abuse? Did you know that experts are predicting an overwhelming increase in senior substance abuse in the coming years? Despite the growing numbers and concerns, the epidemic of substance abuse among seniors is quite hidden and often overlooked. There are many reasons why substance abuse among seniors is not readily recognized. Alcohol and prescription medication use is commonplace in everyday life. Alcohol is used socially and for celebrations. Prescription medication is used to achieve and maintain good health, especially as we age. Yet for many individuals, alcohol and prescription drugs can cause serious problems, including abuse, misuse and addiction. There is still much stigma associated with substance abuse. We are more likely to think of a poor, homeless person as being vulnerable to substance abuse and not Grandma Jane in her Florida retirement home or Great Uncle John playing checkers on the front porch in Memphis. Yet, we all know from our own personal experiences that substance abuse truly does not discriminate. It affects people of all races, ages, genders, sexual orientations, socioeconomic backgrounds and education levels. Older adults are more likely than younger adults to hide their substance abuse, more likely to feel shame about their problem and much less likely to seek help or talk about their problem with family members and friends. Family members of older adults with substance abuse problems, particularly adult children, can feel ashamed of the elder s problem and/or not believe it is really a serious issue, and ignore the situation rather than seek help. On the other hand, an adult child of a senior may feel that, because their parent is older, they have the right to drink or use drugs whatever way they choose.
16 2 Part 1 Health care providers and caretakers often mistake substance abuse and misuse symptoms in older adults for symptoms of common conditions among the elderly, such as depression or dementia. Providers and caretakers can also feel uncomfortable about expressing their concerns and suspicions of senior substance abuse, and may not be aware of programs that specifically address the special needs of seniors. The relationship between aging and substance abuse is not well understood. Researchers are focusing on developing a greater understanding of this relationship and ways to incorporate this understanding into more effective and appropriate screening, prevention and treatment services for seniors. A Growing Problem Like younger people, older adults use, misuse and overuse substances, both legal and illicit. The 2002/2003 National Survey on Drug Use and Health, sponsored by the Substance Abuse and Mental Health Services Administration, indicates that the misuse of alcohol and the use of illicit drugs are increasing among older adults. Illicit drugs include substances such as marijuana, hashish, cocaine, crack, inhalants, hallucinogens, heroin and prescription drugs used nonmedically. Alcohol abuse includes binge drinking and heavy drinking. Medications can be mixed with alcohol and/or illicit drugs. From 1995 to 2002, alcohol was the most frequently reported primary substance of abuse among older adults in treatment services. Men are more likely to abuse alcohol than are women. However, experts believe that alcoholism among women is less frequently recognized, resulting in an underreporting of women as alcohol abusers. During 2002 and 2003, marijuana was the most commonly used illicit drug among older adults, followed by prescription medication used non-medically and cocaine. Among seniors, data indicate that women misuse prescription drugs more frequently than men do. Admissions for substance abuse treatment increased 32 percent among older adults from 1995 to The abuse of opiates, including prescription pain medicines, increased among older adults during this time period, as did heroin abuse.
17 Part 1 3 A Changing Population The senior population is expected to increase significantly over the next several decades, as is the substance abuse epidemic in this age group. This will made it harder to hide or overlook substance abuse in the senior population. By 2050, the U.S. Census Bureau predicts that more than 20 percent of the population will be older than 65 years of age. This translates to approximately 80 million seniors or one out of every four U.S. citizens. By 2030, the Substance Abuse and Mental Health Services Administration estimates that one-third of adults 55 years of age and older will have a substance abuse problem. We are all living longer thanks to advances in medicine, new prescription medications and healthy lifestyle changes. Average life expectancy has increased dramatically over the last several decades. Many young or middle-aged men and women will carry their abuse of alcohol and/or drugs with them as they age and live longer than today s seniors. Seniors 60 and older consume more prescription and over-the-counter drugs than any other age group. This number is expected to increase significantly as the population grows, increasing vulnerability of this age group to prescription drug abuse. The overall increase in alcohol problems throughout the U.S. population, coupled with the aging of Baby Boomers, suggests that the number of older adults with alcohol-related problems will rise. The number of illicit drug users among older adults is likely to increase due to the aging of Baby Boomers, who have a history as a group of higher rates of illicit drug use such as marijuana in their younger years. Reasons for Substance Abuse There are many reasons that people abuse substances and the reasons are as varied as the people who abuse them. For seniors, however, these reasons often correlate with the aging process. We all know that each stage of life brings new challenges and changes. Growing older is no exception. Yet, we seldom think about aging, partly because our society is so focused on staying young. Some of the challenges we all face as we age that factor into the potential for substance abuse include: Retirement: dealing with an often dramatic change in lifestyle and sense of purpose Isolation: fewer social contacts and activities
18 4 Part 1 Grief and loss: the death of a spouse, sibling or close friends; also includes sadness about the loss of social status, occupation and sense of work-related identity and ability to function Increased health problems: physical distress, chronic pain, physical disabilities and handicapping conditions, vision loss, memory loss, hearing loss, added prescription and over-the-counter medications, more doctor visits and more hospitalizations Loss of independence: more difficulty or an inability to perform activities of daily living, not being able to drive, reduced mobility and reduced coping skills Financial changes: increased medical bills, lack of prescription drug insurance, rising cost of living and lowering or loss of income Other reasons for substance abuse later in life can include having experienced substance abuse earlier in life. It is not uncommon for individuals in recovery to experience a relapse after long periods of sobriety. There are many events that can trigger relapse as a person ages, including loss of spouse or friends, loss of income and boredom. In adjusting to the challenges of aging, a person s coping skills can vary considerably. Some individuals find these challenges overwhelming and use coping skills that are inappropriate, including: Drinking or illicit drug use Misusing or overmedicating with prescription drugs Isolation avoiding social interaction, retreating from formerly enjoyable activities and withdrawing from family and friends Sleeping too much Becoming anxious, depressed or fearful Seniors with painful health conditions or chronic pain can overmedicate with prescription drugs and start or increase drinking to cope. Depression and anxiety can result, fueling a dangerous and vicious cycle of drinking and/or abusing drugs to feel better both mentally and physically. There are also many dangers associated with combining alcohol and prescription drugs, as well as overthe-counter drugs.
19 Part 1 5 Special Health Considerations We all know that alcohol and drugs illicit and/or prescription don t mix. Did you know, though, that, as we age, our bodies can develop different and sometimes harmful or even deadly reactions to alcohol and drugs? Given that the average person 65 years old and older takes at least two medicines a day, there is plenty of cause for concern. Keep in mind that over-the-counter medicines and herbal or natural remedies can also cause harmful interactions when combined or mixed with alcohol and drugs. As we age, we become more sensitive to the effects of alcohol, requiring less alcohol to become intoxicated. Aging also affects how drugs are absorbed, processed (metabolized) and released (excreted) from the body. Changes in metabolism affect how quickly and how well a particular medication or drug works. A slower metabolism can also cause drugs to have a more powerful effect on the body s systems and remain in the body for a longer period, thereby increasing the drugs capacity for harm. Kidneys may be less efficient and keep drugs in the body longer, which can cause medicines taken regularly to build to harmful levels. Medical conditions such as high blood pressure, ulcers, angina (chest pain) and diabetes all common in older adults can become worse with alcohol use. Many types of medication prescription and over-the-counter can cause drowsiness and affect coordination. Mixing medications with alcohol and/or illicit drugs can lead to falls, broken bones, serious injuries and car accidents. Older adults are much more at risk for these harmful side effects because, as we age, our motor skills diminish and we lose coordination. We also lose bone density, making falls and accidents a more serious threat to our health and well-being. Memory loss, particularly short-term, can sometimes cause an older person to forget his or her medication or to take too much unintentionally. If the person is also using alcohol or illicit drugs, this can cause harmful effects, particularly if the person has taken too much medication.
20 6 Part 1 Treating Substance Abuse in Seniors Challenges and Barriers to Getting Seniors Into Treatment Older adults typically have more health issues, both physical and mental, than do younger adults. These issues are often interconnected, making diagnosing and treating substance abuse in seniors more complicated than for other age groups. The good news is that research has shown that older adults tend to stay with treatment programs longer than do younger adults, increasing their chances for recovery and improving their health. Research has also shown that overall adults 60 years old and older have higher rates of recovery than any other age group. There are many challenges and barriers to identifying and treating substance abuse in seniors. Special populations may have unique barriers, in addition to the ones mentioned here. Barriers can include: Ageism. This term, first used in the 1960s, describes the tendency for society to assign negative stereotypes to older adults and explain their problems as a function of being old, rather than looking for potential medical or psychological causes. For example, a senior might be described as senile when in fact she or he might have treatable co-occurring conditions such as Alzheimer s disease, depression and alcoholism. Seniors often internalize these stereotypes, making them less likely to seek help for substance abuse or mental health issues. Lack of awareness or denial of a substance abuse problem among seniors. Common among older adults, denial or lack of awareness can be related to complex and early formed attitudes about substance abuse and help-seeking. There is definite stigma associated with the terms alcoholic and drug addict among today s seniors and it is not uncommon for seniors to be reluctant to talk about such problems. Many were taught not to air their dirty laundry in public. Stigma and silence both contribute to a lack of awareness and denial. Many older adults also do not think of substance abuse as a health care problem or disease. They were raised in the well-deserved cocktail after a hard day s work generation, while others feel a great amount of shame because they can t control their substance use. Provider or caregiver difficulty recognizing and correctly identifying a substance abuse problem. Many health conditions and symptoms can interfere with determining substance abuse in seniors. For example, symptoms such as fatigue, irritability and insomnia might be produced by substance abuse, common medical and mental disorders or a combination of these conditions. Shorter health care office visits, a trend that has been occurring for some time, also make it harder to identify a senior s underlying problem with substance abuse.
21 Part 1 7 Seniors are also less likely to have substance abuse diagnosed and are less likely to be referred into treatment during a routine medical care visit. One reason for this is that providers and caregivers might lack an awareness of the benefits of identifying and treating substance abuse in seniors. Research has shown that older adults are more likely to complete treatment and have outcomes that are as good as or better than that of younger adults. The lack of appropriate screening and provider training on recognizing senior-specific signs and symptoms also adds to the difficulty of diagnosing senior substance abuse. Here are some frequently observed symptoms of early problem drinking or chemical abuse/dependency to be aware of: Physical changes, such as unexplained fatigue; night sweating; inability to sleep for more than three to four hours at a time; unexplained appetite or weight changes; flushed face or yellowing of the skin; speech difficulties, such as slurring or repeating oneself; hands or feet shaking or growing unsteady; unexplained cuts and bruises; short-term memory loss; uncontrolled bladder and bowels; swelling of abdominal region, legs or feet; involuntary eye movements, including pupils reacting slowly to light; recent onset of constipation, headaches and backaches; complaints of hearing strange noises; dry mouth and skin; and increased blood pressure or pulse abnormality. Behavioral changes, such as unexplained and sudden mood swings; making careless mistakes; becoming resentful and taking frustration out on others; developing unreasonable fears; listlessness or having no ambition; untidy personal appearance and/or home; undue suspicion of others; noticeable change in sexual activity; decreased attention span and becoming easily distracted; preoccupation with pessimistic thoughts; suicidal thoughts; and depression. Habit changes, such as avoiding old friends and family; unexplained and recent financial difficulty; failure to show up for appointments or work; difficulty in completing tasks; isolating oneself by staying home; drinking alone at home; and starting to drink in the morning. Since all of these symptoms may also have a medical or psychiatric basis, it is important that a comprehensive assessment be conducted before concluding that substance abuse is involved.
22 8 Part 1 Other Barriers. Other barriers that seniors face in accessing services needed in order to get diagnosed and referred into substance abuse treatment include: Being homebound or having restricted mobility. Lack of transportation services, particularly in rural communities. Additionally, doctors might decide against referring seniors to Alcoholics Anonymous (AA) meetings because they cannot walk up stairs or drive after dark. Fewer friends to ask for support or help with things such as transportation. Limited free time if involved with being a caregiver to a spouse, elderly relative or friend. Some seniors might also be the primary caretakers of their grandchildren for a variety of reasons, including substance-abusing parents, further limiting their time. Lack of money or insurance coverage, including payment for substance abuse-related disorders. Language and literacy limitations, especially for seniors whose first language is not English. As just described, there are many complicated and simultaneously occurring barriers and challenges to helping seniors identify and effectively treat substance abuse. We will be addressing these barriers and offering strategies for overcoming them in Part 2 of this manual so that you can be more successful in your work with seniors and substance abuse. Treatment Options and Special Considerations for Seniors This next section gives you a brief overview of treatment options for substance abuse and special considerations when working with seniors. We will begin with the least intensive treatment options brief interventions, intervention and motivational counseling that are recommended to be explored first with older substance abusers as a pre-treatment strategy or as treatment itself. These options can be very effective for seniors, particularly when follow-up and support is offered. For some older adults, however, more intensive treatment is needed, including inpatient/outpatient detoxification; inpatient rehabilitation; residential rehabilitation, including transitional living, recovery or group home housing; and specialized outpatient services. When working with seniors, try to identify treatment options that have specialized services for older adults and be aware of the need for continuing care with seniors once their treatment has been completed.
23 Part 1 9 BRIEF INTERVENTION What It Is Brief intervention strategies are based on concepts and techniques from the motivational psychology and behavior change literature. A brief intervention consists of one or several counseling sessions that can include, depending on the individual s needs: Motivation for change strategies Education, including written educational materials Assessment and direct feedback Contracting and goal setting Behavior modification techniques Special Considerations for Seniors When working with older adults, be sure to incorporate the following items into a brief intervention: Provide feedback on screening questions relating to drinking patterns and other health habits such as nutrition and smoking. Discuss the different types of drinking (social, moderate, heavy) and determine where the senior s patterns fit into the population norms for her or his age group. Clearly convey information on recommended alcohol limits as follows: men and women 60 or older should have no more than one drink a day one drink equals one can (12 ounces) of ordinary beer or ale; a single shot (1.5 ounces) of spirits such as whiskey, vodka or gin; one glass (6 ounces) of wine; a small glass (4 ounces) of sherry; or a small glass (4 ounces) of liqueur or aperitif. Recommended limits are likely to be lower for seniors taking prescription medication. Determine reasons for drinking or drug use such as coping with loss and illness. This will help you gain a better understanding of the role of drinking in the context of the senior s life. Explain the consequences physical, psychological and social of heavier drinking, increased drug use, or a combination of the two. Know that some older adults might already be experiencing these problems, even if they are not heavily using alcohol and/or drugs.